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Blue Advantage® Audits/Reviews

Blue Cross and Blue Shield of Alabama conducts audits in accordance with Medicare laws, rules and regulations. Other audits [such as diagnosis-related groups (DRG) validation, site of care, readmission, etc.] will be conducted as needed. Blue Cross may contract with a vendor as a business associate that is covered by the Health Insurance Portability and Accountability Act (HIPAA) to conduct specific audits and/or reviews. Examples of possible reviews are risk adjustment review and Healthcare Effectiveness Data and Information Set (HEDIS) review.

Medicare records may be requested by mail or obtained by on-site imaging at the provider’s office and/or facility. The onsite reviewer will have the capability to scan and copy medical records as well as the technology to access Electronic Medical Records (EMR) systems. Providers are required to provide medical records in order for Blue Cross to fulfill state and federal regulatory and accreditation obligations. In rare situations where the reviewer cannot copy the records, Blue Cross will reimburse the provider a reasonable cost for the duplication of the medical records.

Blue Advantage is a Medicare-approved PPO Plan.

Last Updated December 2013